'Just knowing what should be happening, or what we think is happening, does not help us make informed decisions'

When you talk about how your department, organisation, process or particular area works, either you are speaking from the experience of days spent observing the process in action or you are speaking from the perspective of what should happen and/or you believe to be happening.

Virtually everyone I have met in the NHS has had some involvement in process mapping, be it on the periphery or actually leading or participating in it.

What I find interesting is that the level of observation that goes into these exercises varies considerably.

At one end of the spectrum it may involve a group of staff - perhaps managers - who go off site or to a meeting room and discuss how a process works. This group may not include anyone who works within the system that is being examined.

At the other end it will be conducted by a group intimately and daily involved in the process.

Just knowing what should be happening, or what we think is happening, does not help us make informed decisions.

Unless we clearly understand what is actually happening, the difference between what is and what should be is lost to us.

I am undertaking a project examining the trauma pathway in a district general hospital.

Before this mapping exercise I spent three weeks meeting representatives of every department that has an impact on the patient's journey. These included:

  • surgeons, anaesthetists, accident and emergency consultants and junior clinicians;

  • nursing staff on the wards and in accident and emergency;

  • radiology and pharmacy staff;

  • occupational and physical therapists.

This period of scoping provided an opportunity to understand the process better and explain why it is necessary, in order to improve a patient's journey, for all groups affecting it to map it and understand how it currently works.

Through this process we established that groups have different beliefs about what is happening. Each group makes decisions based on how they think the system works when it is in fact generally not working in the way that they imagine.

If you have a process to examine, the essential actions are:

  • have a period of preparation during which you meet and consult with those who work in the system;

  • engage clinicians and management - they need to be believe in the value of the project or it will not be sustained;

  • define the problem - if you are unable to articulate succinctly what the problem is, it will be very difficult to solve it;

  • with the participants in the group go to see how the work is carried out in the place where it occurs;

  • identify the root causes of the problems identified;

  • measure what is important, not what is easy. Collect useful data from which informed decisions can be made;

  • change the process - identify all steps in the process that do not add value and eliminate them. Improve the flow of the remaining steps.